Abd El Aziz, Mohamed A

The present large scale study aimed to assess the prevalence and consequences of malnutrition, based on clinical assessment (body mass index and preoperative weight loss) and severe hypoalbuminemia (<3.1 g/L), in a representative US cohort undergoing IBD surgery. The American College of Surgeons National Quality improvement program (ACS-NSQIP) Public User Files (PUF) between 2005 and 2018 were assessed. A total of 25,431 patients were identified. Of those, 6560 (25.8%) patients had severe hypoalbuminemia, 380 (1.5%) patients met ESPEN 2 criteria (≥10% weight loss over 6 months PLUS BMI < 20 kg/m2 in patients <70 years OR BMI < 22 kg/m2 in patients ≥70 years), and 671 (2.6%) patients met both criteria (severe hypoalbuminemia and ESPEN 2). Patients who presented with malnutrition according to any of the three definitions had higher rates of overall, minor, major, surgical, and medical complications, longer LOS, higher mortality and higher rates of readmission and reoperation. The simple clinical assessment of malnutrition based on BMI and weight loss only, considerably underestimates its true prevalence of up to 50% in surgical IBD patients and calls for dedicated nutritional assessment.

Abstract Background There is controversy regarding the postoperative outcomes in Crohn’s disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. Methods All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon’s discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. Results A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. Conclusions This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn’s disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn’s disease. Further studies with larger sample sizes are needed to confirm results.

Aim: The aim of this study was to assess the implementation of an intraoperative standardized surgical site infection (SSI) prevention bundle. Methods: The multimodal, evidence-based care bundle included nine intraoperative items (antibiotic type, timing, and re-dosing; disinfection; induction temperature control > 36.5°; glove change; intra-cavity lavage; wound protection; and closure strategy). The bundle was applied to all consecutive patients undergoing colonic resections. The primary outcome, SSI, was independently assessed by the National Infection Surveillance Committee for up to 30 postoperative days. A historical, institutional pre-implementation control group (2012–2017) with an identical methodology was used for comparison. Findings: In total, 1516 patients were included, of which 1256 (82.8%) were in the control group and 260 (17.2%) were in the post-implementation group. After 2:1 propensity score matching, the groups were similar for all items (p > 0.05). Overall compliance with the care bundle was 77% (IQR 77–88). The lowest compliance rates were observed for temperature control (53% overall), intra-cavity lavage (64% overall), and wound protection and closure (68% and 63% in the SSI group, respectively). Surgical site infections were reported in 58 patients (22.2%) vs. 21.4% in the control group (p = 0.79). Infection rates were comparable throughout the Centers for Disease Control and Prevention (CDC) categories: superficial, 12 patients (4.5%) vs. 4.2%, p = 0.82; deep incisional, 10 patients (3.7%) vs. 5.1%, p = 0.34; organ space, 36 (14%) vs. 12.4%, p = 0.48. After propensity score matching, rates remained comparable throughout all comparisons (all p > 0.05). Conclusions: The implementation of an intraoperative standardized care bundle had no impact on SSI rates. This may be explained by insufficient compliance with the individual measures.

There are limited and discordant results on the comparison between microwave ablation (MWA) and radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC). This meta-analysis aims to compare the two treatments in terms of efficacy and safety, based on a meta-analysis of randomized-controlled trials (RCTs). A computerized bibliographic search was performed on the main databases throughout August 2020. The primary outcome was the complete response rate, while survival rate (at 1-, 2-, 3-, and 5-year), disease-free survival rate (at 1-, 2-, 3-, and 5-year), local and distant recurrence rate, adverse event rate, and number of treatment sessions were the secondary outcomes. Seven RCTs enrolling 921 patients were included. No difference in terms of complete response between the two treatments was observed (risk ratio (RR) 1.01, 95% CI 0.99–1.02). Survival rates were constantly similar, with RRs ranging from 1.05 (0.96–1.15) at 1 year to 0.91 (0.81–1.03) at 5 years. While local recurrence rate was similar between MWA and RFA (RR 0.70, 0.43–1.14), distant recurrence rate was significantly lower with MWA (RR 0.60, 0.39–0.92). Disease-free survival at 1, 2, and 3 years was similar between the two groups with RR 1.00 (0.96–1.04), 0.94 (0.84–1.06), and 1.06 (0.93–1.21), respectively. On the other hand, RR for disease-free survival at 5 years was significantly in favor of MWA (3.66, 1.32–42.27). Adverse event rate was similar between the two treatments (RR 1.06, 0.48–2.34), with bleeding and hematoma representing the most frequent complications. Our results indicate a similar efficacy and safety profile between the two techniques. MWA seems to decrease the rate of long-term recurrences, but this finding needs to be confirmed in further trials.

Despite the advances in screening protocols and treatment options, hepatocellular carcinoma (HCC) is still considered to be the most lethal malignancy in patients with liver cirrhosis. Moreover, the survival outcomes after failure of first-line therapy for unresectable HCC is still poor with limited therapeutic options. One of these options is immune checkpoint inhibitors. The aim of this study is to comprehensively review the efficacy and safety of immune checkpoint inhibitors for patients with HCC.

Inhibition of angiotensin II synthesis seems to decrease hepatocellular carcinoma recurrence after radical therapies; however, data on the adjuvant role of angiotensin II receptor 1 blockers (sartans) are still lacking. Aim of the study was to evaluate whether sartans delay time to recurrence and prolong overall survival in hepatocellular carcinoma patients after radiofrequency ablation. Data on 215 patients were reviewed. The study population was classified into three groups: 113 (52.5%) patients who received neither angiotensin-converting enzyme inhibitors nor sartans (group 1), 59 (27.4%) patients treated with angiotensin-converting enzyme inhibitors (group 2) and 43 (20.1%) patients treated with sartans (group 3). Survival outcomes were analyzed using Kaplan–Meier analysis and compared with log-rank test. In the whole study population, 85.6% of patients were in Child-Pugh A-class and 89.6% in Barcelona Clinic Liver Cancer A stage. Median maximum tumor diameter was 30 mm (10–40 mm) and alpha-fetoprotein was 25 (1.1–2100) IU/mL. No differences in baseline characteristics among the three groups were reported. Median overall survival was 48 months (42–51) in group 1, 51 months (42–88) in group 2, and 63 months (51–84) in group 3 (p = 0.15). Child-Pugh stage and Model for End-staging Liver Disease (MELD) score resulted as significant predictors of overall survival in multivariate analysis. Median time to recurrence was 33 months (24–35) in group 1, 41 (23–72) in group 2 and 51 months (42–88) in group 3 (p = 0.001). Number of nodules and anti-angiotensin treatment were confirmed as significant predictors of time to recurrence in multivariate analysis. Sartans significantly improved time to recurrence after radiofrequency ablation in hepatocellular carcinoma patients but did not improve overall survival.

AbstractUtility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high‐risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high‐risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010‐2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)‐adjusted Kaplan‐Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high‐risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five‐year IPTW‐adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high‐risk pathological features showed an estimated 5‐year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high‐risk features that were treated with adjuvant chemotherapy.